Obesity and Overweight: Probing Causes, Consequences, and Novel Therapeutic Approaches Through the American Heart Association's Strategically Focused Research Network

As the worldwide prevalence of overweight and obesity continues to rise, so too does the urgency to fully understand mediating mechanisms, to discover new targets for safe and effective therapeutic intervention, and to identify biomarkers to track obesity and the success of weight loss interventions. In 2016, the American Heart Association sought applications for a Strategically Focused Research Network (SFRN) on Obesity. In 2017, 4 centers were named, including Johns Hopkins University School of Medicine, New York University Grossman School of Medicine, University of Alabama at Birmingham, and Vanderbilt University Medical Center. These 4 centers were convened to study mechanisms and therapeutic targets in obesity, to train a talented cadre of American Heart Association SFRN-designated fellows, and to initiate and sustain effective and enduring collaborations within the individual centers and throughout the SFRN networks. This review summarizes the central themes, major findings, successful training of highly motivated and productive fellows, and the innovative collaborations and studies forged through this SFRN on Obesity. Leveraging expertise in in vitro and cellular model assays, animal models, and humans, the work of these 4 centers has made a significant impact in the field of obesity, opening doors to important discoveries, and the identification of a future generation of obesity-focused investigators and next-step clinical trials. The creation of the SFRN on Obesity for these 4 centers is but the beginning of innovative science and, importantly, the birth of new collaborations and research partnerships to propel the field forward.

Relative fat mass assessment estimates changes in adiposity among female older adults with obesity after a 12-month exercise and diet intervention

BACKGROUND/OBJECTIVES/INTRODUCTION

It is imperative to accurately estimate whole body fat percentage (%fat) to understand the deleterious nature of excess adiposity on cardiometabolic disease risk. Cost and accessibility often preclude the use of advanced imaging methods like dual-energy X-ray absorptiometry (DXA) and magnetic resonance imaging (MRI). Relative fat mass (RFM) is an emerging estimator of whole body %fat based on waist circumference, height, and biological sex. The purpose of this ancillary study was to examine the relationship between RFM and gold-standard measures of adiposity among community-dwelling older adults with obesity and to evaluate if changes in RFM reflect changes in %fat following a 12-month lifestyle intervention (clinicaltrials.gov #NCT00955903).

PATIENTS/MATERIALS AND METHODS

Participants (N = 163, 37.4% male, 70.3 ± 4.7 years) were randomized to the exercise only group, exercise + nutrient-dense weight maintenance group, or exercise + nutrient-dense energy restriction of 500 kcal/d group. Total and regional adiposity assessed by DXA and MRI, as well as anthropometrics, were evaluated at baseline and 12 months.

RESULTS

RFM was significantly positively correlated with DXA whole body %fat and DXA trunk %fat at baseline. Equivalence testing revealed that RFM was considered equivalent to DXA whole body %fat for females only. Additionally, from baseline to 12 months, a significant reduction in RFM was observed among female participants in the exercise + energy restriction group only. Changes in RFM were significantly correlated with changes in DXA whole body %fat, DXA trunk fat, and total abdominal fat tissue determined by MRI.

CONCLUSION

Results support the use of RFM as an estimate of whole body %fat where advanced imaging techniques are not feasible. Furthermore, results suggest that this index is sensitive to changes in fat mass over 12 months in female older adults with obesity. KEY MESSAGESRelative fat mass (RFM), an emerging estimator of whole body %fat based on waist circumference, height, and biological sex, was intentionally developed to be a simple estimate of adiposity that overcomes limitations of measures like body mass index.In the current study, results from correlations and agreement analyses support the use of RFM to estimate whole-body fat percentage in a community-dwelling older adult population with obesity when advanced methods, namely dual-energy X-ray absorptiometry, are not feasible.Significant reductions in RFM were also observed over a 12-month period that was significantly correlated with changes in whole body fat percentage; thus, supporting the sensitivity of RFM to lifestyle changes.

Harvest for Health, a Randomized Controlled Trial Testing a Home-Based, Vegetable Gardening Intervention Among Older Cancer Survivors Across Alabama: An Analysis of Accrual and Modifications Made in Intervention Delivery and Assessment During COVID-19

BACKGROUND

Accelerated functional decline is a concern among older cancer survivors that threatens independence and quality of life. Pilot studies suggest that vegetable gardening interventions ameliorate functional decline through improved diet and physical activity.

OBJECTIVE

The aim of this article was to describe the rationale, recruitment challenges, and enrollment for the Harvest for Health randomized controlled trial (RCT), which will test the impact of a home-based, vegetable gardening intervention on vegetable and fruit consumption, physical activity, and physical functioning among older cancer survivors. Modifications made to the intervention and assessments to assure safety and continuity of the RCT throughout the COVID-19 pandemic also are reported.

DESIGN

Harvest for Health is a 2-year, 2-arm, single-blinded, wait-list controlled RCT with cross-over.

PARTICIPANTS/SETTING

Medicare-eligible survivors of cancers with ≥60% 5-year survival were recruited across Alabama from October 1, 2016 to February 8, 2021.

INTERVENTION

Participants were randomly assigned to a wait-list control or a 1-year home-based gardening intervention and individually mentored by extension-certified master gardeners to cultivate spring, summer, and fall vegetable gardens.

MAIN OUTCOME MEASURES

Although the RCT's primary end point was a composite measure of vegetable and fruit consumption, physical activity, and physical functioning, this article focuses on recruitment and modifications made to the intervention and assessments during COVID-19.

STATISTICAL ANALYSES PERFORMED

χ2 and t tests (α < .05) were used to compare enrolled vs unenrolled populations.

RESULTS

Older cancer survivors (n = 9,708) were contacted via mail and telephone; 1,460 indicated interest (15% response rate), 473 were screened eligible and consented, and 381 completed baseline assessments and were randomized. Enrollees did not differ from nonrespondents/refusals by race and ethnicity, or rural-urban status, but comprised significantly higher numbers of comparatively younger survivors, those who were female, and survivors of breast cancer (P < .001). Although COVID-19 delayed trial completion, protocol modifications overcame this barrier and study completion is anticipated by June 2022.

CONCLUSIONS

This RCT will provide evidence on the effects of a mentored vegetable gardening program among older cancer survivors. If efficacious, Harvest for Health represents a novel, multifaceted approach to improve lifestyle behaviors and health outcomes among cancer survivors-one with capacity for sustainability and widespread dissemination.

Changes in Cardiometabolic Risk Among Older Adults with Obesity: An Ancillary Analysis of a Randomized Controlled Trial Investigating Exercise Plus Weight Maintenance and Exercise Plus Intentional Weight Loss by Caloric Restriction

BACKGROUND

Obesity imposes risk to cardiometabolic health; however, intentional weight loss among older adults with obesity remains controversial.

OBJECTIVE

To explore the influence of exercise plus weight maintenance and exercise plus intentional weight loss by caloric restriction on changes in cardiometabolic risk among older adults with obesity assessed by four risk-scoring tools.

DESIGN

Using longitudinal data from the Calorie Restriction and Changes in Body Composition, Disease, Function, and Quality of Life in Older Adults study (CROSSROADS) (ClinicalTrials.gov identifier: NCT00955903; May 2009 to October 2014), scores were calculated using baseline and 12-month data according to criteria from the International Diabetes Federation, National Cholesterol Education Program's Adult Treatment Panel, Framingham Risk Score, and Cardiometabolic Disease Staging.

PARTICIPANTS AND SETTING

Participants (39% men, 23% African American, aged 70.2 ± 4.7 years) were randomized to exercise (n = 48), exercise plus nutrient-dense weight maintenance diet (n = 44), or exercise plus weight loss by moderate caloric restriction (n = 42).

MAIN OUTCOME MEASURES

To evaluate effects of exercise plus weight maintenance and exercise plus intentional weight loss on changes in cardiometabolic risk.

STATISTICAL ANALYSES PERFORMED

Generalized estimating equations were used to assess changes in risk with ethnicity, biological sex, and age as covariates.

RESULTS

Group-time interaction was only significant for Framingham and Cardiometabolic Disease Staging (P = 0.005 and 0.041, respectively). Upon post hoc analysis, significant within-group improvements in Framingham scores were observed for exercise plus weight maintenance (P < 0.001; r = -1.682) and exercise plus weight loss (P = 0.020; r = -0.881). In analysis of between-group differences in Framingham scores, significant decreases were observed in the exercise plus weight maintenance group (P = 0.001; r = -1.723) compared with the exercise group. For Cardiometabolic Disease Staging, the exercise plus weight loss group had significant within-group improvements (P = 0.023; r = -0.102). For between-group differences in Cardiometabolic Disease Staging, the exercise plus weight loss group showed significant risk reduction (P = 0.012; r = -0.142) compared with the exercise group.

CONCLUSIONS

Among risk scores evaluated, Framingham and Cardiometabolic Disease Staging showed significantly greater sensitivity to change in cardiometabolic risk. Older adults with obesity can significantly lower cardiometabolic risk through exercise plus weight maintenance or exercise plus weight loss by moderate caloric restriction.

Rural and Urban Differences in Vegetable and Fruit Consumption Among Older Cancer Survivors in the Deep South: An Exploratory Cross-Sectional Study

BACKGROUND

Cancer survivors, especially those who are older, experience increased comorbidity and risk for secondary cancers. A varied dietary pattern, rich in vegetables and fruit (V&F) is recommended to improve health. However, V&F intake may differ by rural versus urban status.

OBJECTIVE

To assess differences in V&F consumption among older cancer survivors residing in urban- and rural-designated areas, and explore whether differences exist by sex, race, and cancer type.

DESIGN

This was a cross-sectional secondary analysis.

PARTICIPANTS/SETTING

Screening data from the Harvest for Health trial were obtained from October 2016 to November 2019 on 731 Medicare-eligible cancer survivors across Alabama.

MAIN OUTCOME MEASURES

V&F consumption was measured by 2-items from the Eating at America's Table NCI Dietary Screener. Rural and urban residence was coded at the zip-code level using the USDA's Rural-Urban Commuting Area (RUCA) coding schema using five different classifications (A-E). Sex, race and cancer-type were dichotomized as male/female, Non-Hispanic White (NHW)/Non-Hispanic Black (NHB) and gastro-intestinal/other cancers, respectively.

STATISTICAL ANALYSES

Kruskal Wallis rank sum and post-hoc tests were performed to detect differences in V&F consumption (α<0.05).

RESULTS

The study sample was largely female (66.2%), NHW (78.1%), of mean age 70 years and reported an average V&F intake of 1.47 cups/day. V&F consumption of cancer survivors living in isolated, small, rural towns was roughly half that consumed by survivors living elsewhere; thus, statistically significant rural-urban differences were found in models that accounted specifically for this subgroup, i.e., RUCA categorizations A and E.V&F consumption also was significantly lower in NHB (1.32 ± 0.98 cups/day) than NHW survivors (1.51 ± 1.10 cups/day) (p=0.0456); however, no statistically significant differences were detected by sex and cancer type.

CONCLUSION

Analyses that address the variability within "rural" designated areas are important in future studies. Moreover, a greater understanding is needed of factors that adversely affect V&F consumption of those most vulnerable, i.e., older NHB cancer survivors as well as those living in isolated, small, rural towns to best target future interventions.

Daily 100% watermelon juice consumption and vascular function among postmenopausal women: A randomized controlled trial

BACKGROUND AND AIMS

Watermelon juice is a rich food source of cardioprotective compounds such as arginine, citrulline, and lycopene. Preventative interventions are warranted as risk of cardiovascular disease increases among women after menopause, and age alone is an independent risk factor for vascular dysfunction. Thus, this study evaluated the effects of 100% watermelon juice on measures of vascular function.

METHODS AND RESULTS

In this randomized, double-blind, placebo-controlled, crossover trial, 21 healthy postmenopausal women were randomized to consume two 360 mL servings of 100% watermelon juice per day or an isocaloric placebo for four weeks. Following a two-week washout period, they consumed the other beverage for an additional four weeks. Before and after each treatment arm, a fasting blood sample was taken for measurement of serum arginine, citrulline, lycopene, glucose, and insulin. Assessments of vascular function included pulse pressure, pulse wave velocity, 24-h ambulatory blood pressure, and flow-mediated dilation. General linear mixed models with intent-to-treat analyses were used to examine the effects of the intervention. Despite a significant treatment effect for circulating lycopene (p = 0.002), no changes in arginine, citrulline, or any vascular measures were observed. Although the juice intervention resulted in a slight but significant increase in fasting serum glucose (p = 0.001), changes in glucose homeostasis were not clinically significant.

CONCLUSION

In contrast to findings from previous studies in younger adults and those with pre-existing hypertension, measures of vascular function in this cohort of healthy postmenopausal women were not impacted by supplemental watermelon juice. CLINICALTRIALS.

GOV IDENTIFIER

NCT03626168.

The Effect of Low-Carbohydrate and Low-Fat Diets on Pain in Individuals with Knee Osteoarthritis

OBJECTIVE

Osteoarthritis is the most prominent form of arthritis, affecting approximately 15% of the population in the United States. Knee osteoarthritis (KOA) has become one of the leading causes of disability in older adults. Besides knee replacement, there are no curative treatments for KOA, so persistent pain is commonly treated with opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs. However, these drugs have many unpleasant side effects, so there is a need for alternative forms of pain management. We sought to test the efficacy of a dietary intervention to reduce KOA.

DESIGN

A randomized controlled pilot study to test the efficacy of two dietary interventions.

SUBJECTS

Adults 65-75 years of age with KOA.

METHODS

Participants were asked to follow one of two dietary interventions (low-carbohydrate [LCD], low-fat [LFD]) or continue to eat as usual (control [CTRL]) over 12 weeks. Functional pain, self-reported pain, quality of life, and depression were assessed every three weeks. Serum from before and after the diet intervention was analyzed for oxidative stress.

RESULTS

Over a period of 12 weeks, the LCD reduced pain intensity and unpleasantness in some functional pain tasks, as well as self-reported pain, compared with the LFD and CTRL. The LCD also significantly reduced oxidative stress and the adipokine leptin compared with the LFD and CTRL. Reduction in oxidative stress was related to reduced functional pain.

CONCLUSIONS

We present evidence suggesting that oxidative stress may be related to functional pain, and lowering it through our LCD intervention could provide relief from pain and be an opioid alternative.

100% Watermelon Juice as a Food-First Intervention to Improve Cognitive Function: Ancillary Findings from a Randomized Controlled Trial

Lycopene exhibits neuroprotective properties due to its antioxidant and anti-inflammatory functionality. As watermelon is a rich source of lycopene, pasteurized watermelon juice provides lycopene in its most bioavailable form. This study examined relationships between circulating lycopene, cognitive performance, and biomarkers of oxidative stress and inflammation in response to pasteurized 100% watermelon juice supplementation. A placebo-controlled, randomized, double-blind, crossover trial was conducted with postmenopausal women (n = 16, 60 + 4.1 years). Participants consumed two 360 mL servings of pasteurized 100% watermelon juice or a placebo beverage for 4 weeks. Fasting blood samples were collected, and cognitive tests were administered to assess various neurocognitive domains. Statistical analyses included mixed models and Spearman correlations. Serum lycopene exhibited a significant treatment effect (p = 0.002) with a mean increase of 81%. However, this increase was not associated with changes in oxidative stress, inflammation, or cognitive function. Additional research is warranted to determine dose-durational effects for promoting cognition.

Epigenetic stratification of head and neck cancer survivors reveals differences in lycopene levels, alcohol consumption, and methylation of immune regulatory genes

BACKGROUND

Inflammation has been associated with higher rates of recurrence and mortality in head and neck cancer (HNC). While the biological mechanisms predisposing patients to heightened inflammatory states remain largely unknown, DNA methylation has been proposed to reflect systemic inflammation. In this analysis, we attempt to identify meaningful epigenetic patterns in HNC survivors by stratifying individuals based on DNA methylation profiles in leukocytes.

RESULTS

We used hierarchical clustering to uncover three distinct methylation patterns among HNC survivors. Each group displayed a unique methylation signature in inflammatory pathways including cytokine and B-cell receptor signaling. Additionally, we examined physiological, clinical, and lifestyle parameters related to inflammation, such as circulating carotenoid and cytokine levels, cancer treatment type, and alcohol consumption. Specifically, we identified one group of survivors who had significant differential methylation of transcriptional and translational regulators as well as genes in the T-cell receptor signaling pathway, including hypermethylation of CD40 ligand (CD40LG) and Tec protein tyrosine kinase (TEC) and hypomethylation of CD8A. This group also displayed high circulating lycopene levels. We identified another group that had distinctive methylation in the toll-like receptor (TLR) signaling pathway, including hypomethylation of TLR5, a component of the inhibitor of nuclear factor-kappa B kinase complex (CHUK), and two mitogen-activated protein kinases (MAP3K8 and MAP2K3). This group also had hypermethylation of mitochondrial ribosomal genes along with higher rates of alcohol consumption.

CONCLUSION

The correlation between lycopene, alcohol consumption, DNA methylation, and inflammation warrants further investigation and may have implications in future recommendations and interventions to impact health outcomes in HNC survivors.

Variation of Serum Lycopene in Response to 100% Watermelon Juice: An Exploratory Analysis of Genetic Variants in a Randomized Controlled Crossover Study

BACKGROUND

Watermelon, a rich source of lycopene, has garnered attention for cardioprotective effects including cholesterol reduction and promotion of redox balance. It is unknown whether 100% watermelon juice may represent a food-first approach to confer cardioprotective benefits of lycopene.

OBJECTIVES

This study examined influences of 100% watermelon juice on serum lycopene, lipids, and antioxidant capacity. Secondly, the study explored genetic influences on lycopene metabolism and bioavailability.

METHODS

A placebo-controlled, randomized, double-blind, crossover trial with postmenopausal women (n = 16, mean ± SD age: 60 ± 4.1 y) assessed effects of 100% watermelon juice on mechanistic and clinical outcomes influencing vascular function. Participants maintained low-lycopene diets for a 1-wk run-in period and throughout the study. Morning and evening consumption of 100% watermelon juice provided a daily dose of 14.4 ± 0.34 mg lycopene. Study arms of 4 wk were separated by a 2-wk washout period. Saliva was collected for genetic analysis of single nucleotide polymorphisms, and fasting blood samples were taken pre- and post-study arms. Statistical analyses included mixed models, linear regression, and nonparametric tests.

RESULTS

Serum lycopene exhibited a significant treatment effect (P = 0.002) along with notable interindividual responses; however, significant improvements in serum lipids or antioxidant capacity were not observed. Genetic variant rs6564851 in the β-carotene 15,15'-oxygenase-1 (BCO1) gene was associated with changes in lycopene such that TT homozygotes exhibited a significantly greater increase (β ± SE: 13.4 ± 1.6, P = 1.4 × 10-06).

CONCLUSIONS

Watermelon juice supplementation did not result in improvements in serum lipids or antioxidant capacity; however, results support findings in which watermelon juice significantly, yet differentially, increased circulating lycopene. Genetics appears to explain some of the variability. Given that dose has been shown to overcome individual responsiveness to lycopene interventions, future investigations with varying doses of lycopene-rich foods would be strengthened by genotyping so as to establish personalized nutrition recommendations.This trial was registered at clinicaltrials.gov as NCT03626168.

Head and neck cancer survivors' preferences for and evaluations of a post-treatment dietary intervention

BACKGROUND

Dietary preferences vary depending on cancer type. The purpose of this study was to report dietary intervention preferences and a study program evaluation from post-treatment head and neck cancer survivors participating in a dietary intervention.

METHODS

Between January 2015 and August 2016, 24 head and neck cancer survivors participated in a 12-week randomized clinical dietary intervention trial that promoted weekly consumption of 2.5 cups of cruciferous vegetables and 3.5 cups of green leafy vegetables. At study completion, survivors completed a preferences survey and a study program evaluation to probe interests and improvement aspects for planning future dietary intervention trials. Descriptive statistics (means and frequencies) were generated for multiple choice question responses. Responses to open-ended questions were recorded and grouped based on themes, and verified by quality assurance checks by a second study team member.

RESULTS

Twenty-three survivors completed the preferences and evaluation surveys (response rate 96%). Overall, most participants reported a preference for one-on-one telephone counseling from a registered dietitian nutritionist before beginning treatment. Ninety-six percent of participants ranked the overall study program as "very good" to "excellent," and all agreed the objectives of the study were clear, the study staff was helpful and easy to contact, and the registered dietitian nutritionist was knowledgeable.

CONCLUSIONS

Future research and dietary intervention planning for head and neck cancer survivors should focus on strategies to promote one-on-one telephone or other distance-based counseling combined with face-to-face visits, according to survivor preference.

Dietary Quality Assessed by the HEI-2010 and Biomarkers of Cardiometabolic Disease: An Exploratory Analysis

Objectives: This study explores relationships between cardiometabolic measures of antioxidant capacity or inflammation and diet quality assessed by the Healthy Eating Index (HEI)-2010 which measures conformity to Dietary Guidelines for Americans. This cross-sectional study was an ancillary analysis of baseline data for a randomized controlled trial with older adults at risk for cardiometabolic disease (ClinicalTrials.gov #NCT00955903). Methods: Community-dwelling older adults (n = 133, 49% male, 70.4 ± 4.8 years) with a body mass index of 30-40 kg/m² provided a fasted blood sample for measurement of antioxidant capacity, high-sensitivity C-reactive protein, tumor necrosis factor-alpha, and interleukin-6. Dietary data were generated from the mean of three 24-hour recalls. Results: After adjustment for potential confounders, HEI-2010 composite scores were not significantly associated with decreased inflammation or greater antioxidant capacity. In analysis of the 12 components composing the HEI-2010, significant positive association was observed between total dairy and total serum antioxidant capacity (0.043; 95% CI, 0.008-0.069). Significant associations observed in inflammatory markers were between total vegetable and tumor necrosis factor-alpha (-0.078; 95% CI, -0.151 to -0.005), sodium and interleukin-6 (0.091; 95% CI, 0.023-0.158), and scores for combined calories from solid fats, alcoholic beverages, and added sugars and interleukin-6 (0.139; 95% CI, 0.027-0.252). In models adjusting for HEI-2010 composite score when significant associations were observed between component scores and biomarkers, two of six associations were strengthened by adding the composite score as a potential confounder. Conclusions: Largely null findings along with those inconsistent with scientific expectations suggest caution in extrapolating adherence to the HEI-2010 with an individual's inflammatory or antioxidant status. Results merit additional investigation with other biomarkers of chronic disease and emphasis on dietary patterns given potential synergy within food combinations.

Understanding the Dietary Habits of Black Men With Diabetes

Diabetes is highly prevalent in African American men. To provide nurse practitioners with practice strategies we explored African American men's perceived needs for dietary health and diabetes self-management using the Social Cognitive Theory. Twenty-five African American men participated in four focus groups. The data were analyzed using a combination of inductive/deductive content analysis approach. Focus group analysis identified personal, behavioral and environmental barriers to and facilitators for diabetes self-management. Nurse practitioners may need to provide extra emotional support in the absence of informal social support from families for diabetes self-management and dietary health in African American men with diabetes.

Radiation Oncologist Characteristics and their Association with Outcomes in Patients with Head and Neck Cancer

PURPOSE

Intensity modulated radiation therapy (IMRT) is widely used in the treatment of head and neck cancers (HNC). There is not enough evidence to suggest that some radiation oncologists (ROs) are associated with better outcomes in patients with HNC. We conducted a cross-sectional analysis to evaluate the effect of ROs' characteristics on outcomes in patients with HNC treated with IMRT.

METHODS AND MATERIALS

The study used the Surveillance Epidemiology and End Results-Medicare linked database to identify patient characteristics. Physician records were obtained from the American Medical Association. Logistic regression models with propensity scores were analyzed to look for an association between RO characteristics and patient outcomes.

RESULTS

RO characteristics showed that approximately 30% of ROS completed their training in or after the year 2000 (recently trained), and 17% were in top decile of treatment volume (high volume). Less than 3% of ROs work in academic settings. We found that ROs who were recently trained have higher odds (odds ratio [OR]: 1.10; 95% confidence interval [CI], 1.011-1.191) compared with those who were not. In addition, ROs who were treating high volumes of patients have higher odds (OR: 1.08; 95% CI, 1.010-1.165) compared with those treating low volumes of an event of adverse effect of IMRT or death among patients. ROs who work in academic settings have a protective effect (OR: 0.72; 95% CI, 0.569-0.925).

CONCLUSIONS

ROs who were recently trained and had a high treatment volume are associated with poorer outcomes among patients with HNC who receive IMRT treatment.

Feasibility Outcomes of a Pilot Randomized Clinical Trial to Increase Cruciferous and Green Leafy Vegetable Intake in Posttreatment Head and Neck Cancer Survivors

BACKGROUND

Higher intakes of cruciferous vegetables (CVs) and green leafy vegetables (GLVs) in observational studies are associated with improvements in survival and cancer-related biomarkers in patients diagnosed with head and neck cancer (HNC). These results have yet to be corroborated in a randomized clinical trial (RCT).

OBJECTIVE

Determine the feasibility of implementing a 12-week RCT to increase CV and GLV intake in posttreatment HNC survivors.

DESIGN AND PARTICIPANTS

This was a two-arm RCT conducted among 24 posttreatment HNC survivors. Survivors were recruited from a southeastern, National Cancer Institute-designated Comprehensive Cancer Center between January 2015 and September 2016.

INTERVENTION

There were two groups: (1) an experimental group (n=12) receiving weekly 15- to 30-minute telephone dietary counseling from a registered dietitian nutritionist stressing 2.5 cups per week CVs and 3.5 cups per week GLVs, and (2) an attention control group (n=12) receiving weekly 15- to 30-minute telephone dietary counseling from a registered dietitian nutritionist focusing on general healthy eating for cancer survivors. Participants completed a baseline survey, three 24-hour dietary recalls, phlebotomy, and anthropometric measures prior to randomization and at the end of the 12-week study period. The experimental group also completed weekly vegetable record recalls.

MAIN OUTCOME MEASURES

Primary outcomes included feasibility, recruitment, retention, adherence, and safety. Secondary outcomes included inflammatory markers and carotenoids.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics were generated for demographic, epidemiological, and clinical variables as well as the primary feasibility outcomes. Between- and within-group comparisons of mean serum cytokine and carotenoid levels were performed using appropriate statistical tests depending on their respective distributions for the purpose of generating preliminary effect sizes.

RESULTS

Overall, 350 incident HNC cases were screened for eligibility, and 98 were eligible for study participation. Reasons for ineligibility and exclusion included deceased (n=93); wrong or inactive telephone numbers, or unable to be reached, or lost to follow-up (n=93); not meeting inclusion criteria (n=39); and too ill to participate (n=27). Of the 98 eligible HNC cases, 24 agreed to participate, for an enrollment rate of 25%. The most common reason for nonparticipation was distance (n=48), as participants were asked to report for two on-site assignments. The retention rate was 96%. Mean intervention adherence rates for weekly goals were 67% CV, 74% GLV, and 71% overall. Completion rate of weekly counseling calls was 90%. The experimental group reported an overall mean increase of 5.5 cups GLV and 3.5 cups CV per week from baseline intake, respectively. No significant between- or within-arm differences were observed for inflammatory markers or carotenoids.

CONCLUSION

A posttreatment intervention aimed at increasing CV and GLV intake in HNC survivors is feasible. A larger RCT is needed to assess the efficacy of this intervention on disease outcomes.

Physical Function and Strength in Relation to Inflammation in Older Adults with Obesity and Increased Cardiometabolic Risk

BACKGROUND

Inflammation is implicated in functional decline and the development of disability in aging. This study aimed to investigate the association of inflammation with physical function and muscle strength in older adults with obesity and increased cardiometabolic risk.

DESIGN

In baseline assessments from the CROSSROADS randomized controlled trial, serum interleukin-6 (IL-6), tumor necrosis factor-α (TNFα) and C-reactive protein (hs-CRP) were assayed in 163 older adults (37% males, 24% African American, BMI 34±3, age 70±5yrs) with hypertension, dyslipidemia and/or diabetes. Physical function was assessed by six-minute walk test (6MWT), chair sit-and-reach (CSR), hand-grip and knee-extension strength; specific-strength as muscle strength/mass ratio. Analyses included ANCOVA and multiple linear regression adjusted for thigh skeletal muscle (MRI), arm lean mass (DXA) and moderate-to-vigorous intensity physical activity (MVPA; accelerometry).

RESULTS

Higher hs-CRP (p<0.01) and IL-6 (p=0.07) were associated with lower 6MWT and CSR, respectively. A composite inflammation score combining all 3 inflammatory markers showed the strongest inverse association with 6MWT (p<0.01). MVPA moderated associations such that amongst participants who engaged in low MVPA, 6MWT distances and CSR scores were significantly lower in those with high IL-6 and TNFα (p<0.05), respectively. In participants with high MVPA, higher hs-CRP (p<0.05) and TNFα (p=0.07) were associated with poorer upper-extremity specific-strength.

CONCLUSIONS

Chronic inflammation was associated with poorer physical function and specific strength in older adults with obesity and increased cardiometabolic risk. This association was strongest in participants with multiple elevated inflammatory markers. Physical activity levels below current recommendations mitigated the deleterious effects of inflammation on lower body mobility, underscoring the benefits of exercise for preserving physical function with age.

A home-based mentored vegetable gardening intervention demonstrates feasibility and improvements in physical activity and performance among breast cancer survivors

BACKGROUND

The current study assessed the feasibility of a mentored home-based vegetable gardening intervention and examined changes in health-related outcomes among breast cancer survivors (BCS).

METHODS

BCS were randomized to either a year-long vegetable gardening intervention to begin immediately or a wait-list control. Master Gardeners mentored participants in planning, planting, and maintaining 3 seasonal gardens over the course of 1 year. Participant accrual, retention, and satisfaction rates of ≥80% served as feasibility (primary outcome) benchmarks. Secondary outcomes (ie, vegetable consumption, physical activity, performance and function, anthropometrics, biomarkers, and health-related quality of life) were collected at baseline and post-intervention (1-year follow-up) using subjective and objective measures.

RESULTS

The trial surpassed all feasibility benchmarks at 82% of targeted accrual, 95% retention, and 100% satisfaction (ie, experience ratings of "good to excellent" and willingness to "do it again"). Compared with the controls, intervention participants reported significantly greater improvements in moderate physical activity (+14 vs -17 minutes/week) and demonstrated improvements in the 2-Minute Step Test (+22 vs + 10 steps), and Arm Curl (+2.7 vs + 0.1 repetitions) (P values < .05). A trend toward improved vegetable consumption was observed (+0.9 vs + 0.2 servings/day; P = .06). Approximately 86% of participants were continuing to garden at the 2-year follow-up.

CONCLUSIONS

The results of the current study suggest that a mentored, home-based vegetable gardening intervention is feasible and offers an integrative and durable approach with which to improve health behaviors and outcomes among BCS. Harvest for Health led to the establishment of a group of trained Master Gardeners and gave rise to local and global community-based programs. Larger studies are needed to confirm the results presented herein and to define applicability across broader populations of survivors.

Assessing the Feasibility of a Mentored Home-Based Vegetable Gardening Intervention among Breast Cancer Survivors in the Deep South

To assess the feasibility of a mentored home-based vegetable gardening intervention among Breast Cancer Survivors (BCS) residing in the Birmingham, Alabama metropolitan area. Methods: Using a wait-list control design, BCS were randomized to either a year-long vegetable gardening intervention or a wait-list control. Intervention participants were provided with necessary supplies and paired with a Master Gardener from the Cooperative Extension. Master Gardeners mentored participants in planning, planting, and maintaining 3 seasonal gardens over 12 months, conducted monthly home-visits, and checked in bi-weekly via telephone or email. Feasibility assessment criteria consisted of participant accrual, retention, and satisfaction rates of ≥80%. Target participant accrual was 100. Participant satisfaction data were collected after study completion via structured telephone debriefing. Descriptive statistics were conducted using SPSS V24. Results: 82 BCS (Mage = 60 (39–84); Msurvivorship = 5 years (0.5–23); Mco-morbidities = 3.5 (0–12); ≥2 functional limitations = 86.6%; Caucasian = 73.2%; African-American = 26.8%) enrolled (82% accrual). Of these, four did not complete the study (2 refused to be wait-listed due to not wanting to wait to garden, 1 withdrew due to family obligations, and 1 was lost to follow-up), resulting in an retention rate of 95% over a 1-year period. All BCS who completed the intervention (n = 42) rated their Harvest for Health experience as “Good to Excellent”, reported that they would “do it again”, and planned to “continue to garden.” When asked to rate, on a scale of 1–10 (1 = not at all and 10 = very much), the influence of gardening on motivating behavior change, BCS reported that gardening motivated them to… “eat a healthier diet” (M = 8.38; SD = 2.07), “eat more vegetables” (M = 8.43; SD = 2.08), and “be more physically active” (M = 7.5; SD = 2.73). Conclusions: The vegetable gardening intervention proved to be feasible and provided new knowledge about the influence of gardening on motivating behavior change among BCS. Findings suggest that a mentored home-based vegetable gardening may offer an integrative approach to improve diet, vegetable consumption, and physical activity among BCS. Larger, future studies are warranted.

A High-Fat Compared with a High-Carbohydrate Breakfast Enhances 24-Hour Fat Oxidation in Older Adults

Background

The ability to oxidize fat is associated with a lower risk of chronic metabolic disease. Preclinical data in mice showed that a high-fat "breakfast" increased 24-h fat oxidation relative to a high-carbohydrate breakfast.

Objectives

The objectives of this study were to determine whether the timing of macronutrient intake in humans affects daily fuel utilization and to examine associations between fuel utilization and metabolic indexes.

Methods

Participants were 29 healthy sedentary men and women (aged 55-75 y) with a body mass index (kg/m2) between 25 and 35. Participants were randomly assigned to receive either a high-fat breakfast (FB; 35% carbohydrate, 20% protein, 45% fat; n = 13) or a high-carbohydrate breakfast (CB; 60% carbohydrate, 20% protein, 20% fat; n = 16) for 4 wk while consuming a "neutral" lunch and dinner. Twenty-four-hour and postprandial respiratory quotients (RQs) were measured by whole-room indirect calorimetry. Insulin and glucose measures including insulin sensitivity were determined by an oral-glucose-tolerance test. Measures were taken at baseline and after the 4-wk intervention. Group-by-time interactions were determined by 2-factor repeated-measures mixed-model ANOVA. Pearson's correlation analyses were used to determine associations of 24-h RQs with metabolic measures after the intervention.

Results

There was a significant group-by-time interaction for change in the 24-h RQ [FB (mean ± SD): 0.88 ± 0.02 to 0.86 ± 0.02; CB: 0.88 ± 0.02 for both; P < 0.05], breakfast RQ (FB: 0.88 ± 0.03 to 0.86 ± 0.03; CB: 0.89 ± 0.02 to 0.90 ± 0.02; P < 0.01), and lunch RQ (FB: 0.089 ± 0.03 to 0.85 ± 0.03; CB: 0.89 ± 0.03 for both; P < 0.01). In the CB group at follow-up, 24-h RQ was positively associated with fasting glucose (r = 0.66, P < 0.05), glucose area under the curve (AUC) (r = 0.51, P < 0.05), and insulin AUC (r = 0.52, P < 0.05) and inversely associated with insulin sensitivity (r = -0.51, P < 0.05).

Conclusions

The macronutrient composition of breakfast affects substrate utilization throughout the day in older adults. The consumption of a high-fat, lower-carbohydrate breakfast may reduce the risk of metabolic disease. This trial was registered at www.clinicaltrials.gov as NCT03164200.

Social and Demographic Predictors of Nutritional Risk: Cross-sectional Analyses From the UAB Study of Aging II

Social factors may disparately affect access to food and nutritional risk among older adults by race and gender. This study assesses these associations using the Mini Nutritional Assessment among 414 community-dwelling persons 75+ years of age in Alabama. Descriptive analyses on the full sample and by African American men, African American women, white men, and white women showed that mean scores for the full Mini Nutritional Assessment differed by groups, with African American men and African American women having the highest nutritional risk. Multivariable analyses indicated that social factors affect nutritional risk differently by race and gender. Nutritional risk interventions are warranted for older adults.

Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial

Background

We lack a comprehensive assessment of the risks and benefits of calorie restriction in older adults at high risk for cardiometabolic disease. Calorie restriction may reduce visceral adipose tissue (VAT) but also have negative effects on lean mass and quality of life.

Methods

We conducted a 52-week, randomized controlled trial involving 164 older adults with obesity taking at least one medication for hyperlipidemia, hypertension, or diabetes. Interventions included an exercise intervention alone (Exercise), or with diet modification and body weight maintenance (Maintenance), or with diet modification and energy restriction (Weight Loss). The primary outcome was change in VAT at 12 months. Secondary outcomes included cardiometabolic risk factors, functional status, and quality of life.

Results

A total of 148 participants had measured weight at 12 months. Despite loss of -1.6% ± 0.3% body fat and 4.1% ± 0.7% initial body weight, Weight Loss did not have statistically greater loss of VAT (-192.6 ± 185.2 cm3) or lean mass (-0.4 ± 0.3 kg) compared with Exercise (VAT = -21.9 ± 173.7 cm3; lean mass = 0.3 ± 0.3 kg). Quality of life improved in all groups with no differences between groups. No significant changes in physical function were observed. Weight Loss had significantly greater improvements in blood glucose (-8.3 ± 3.6 mg/dL, p < .05) and HDL-cholesterol (5.3 ± 1.9, p < .01) compared with Exercise. There were no group differences in the frequency of adverse events.

Conclusions

While moderate calorie restriction did not significantly decrease VAT in older adults at high risk for cardiometabolic disease, it did reduce total body fat and cardiometabolic risk factors without significantly more adverse events and lean mass loss.

Modulating Oxidative Stress and Inflammation in Elders: The MOXIE Study

Cardiovascular disease (CVD) is the leading cause of death among women in the United States. Endothelial dysfunction and arterial stiffness increase with advancing age and are early predictors of future CVD outcomes. We designed the Modulating Oxidative Stress and Inflammation in Elders (MOXIE) study to examine the effects of 100% watermelon juice as a "food-first" intervention to reduce CVD risk among African American (AA) and European American (EA) women aged 55-69 years. Vascular dysfunction is more pronounced in AA compared to EA women due in part to lower nitric oxide bioavailability caused by higher oxidative stress. However, bioactive compounds in watermelon may improve vascular function by increasing nitric oxide bioavailability and antioxidant capacity. This trial will use a randomized, placebo-controlled, crossover design to investigate the potential of 100% watermelon juice to positively impact various robust measures of vascular function as well as serum biomarkers of oxidative stress and antioxidant capacity. This nutrition intervention and its unique methodology to examine both clinical and mechanistic outcomes are described in this article.

Associations between participation in family activities and adolescent school problems

INTRODUCTION

Adolescent risk outcomes related to school issues are widespread, with about 20% parents reporting poor school engagement amongst their youth. Previous literature suggests that adolescents who report strong bonds with their parents are often identified as being less likely to engage in risky behaviours, such as substance use. The current study sought to examine the association between the frequencies of selected family activities and school problems amongst adolescents after adjustments for family connectedness and other characteristics.

METHODS

Data were drawn from the National Longitudinal Survey of Youth, 1997. Of the 8984 youth interviewed, 3855 also had a sibling interviewed who met the selection criteria. School problem outcomes measured were suspension occurrence, poor grades and highest grade completed low for age. Independent variables of interest were self-reported frequency of family dinner, fun and religious activities in a typical week. Multivariable logistic models were estimated for each outcome, and multivariable linear probability models were estimated adjusting for family fixed effects.

RESULTS

Adjusting for family connectedness, there were significant associations between certain family activities and adolescent school problem measures. However, these results did not remain significant in models with family fixed effects, suggesting that associations could be driven by family-level confounders.

DISCUSSION

This study did not find strong evidence of a protective relationship between family activities and school problems. Therefore, it suggested that programme and policymakers be cautious in overstating the importance of family activities in preventing adolescent risk outcomes until true causal relationships can be determined.

Cardiovascular Health and Healthcare Utilization and Expenditures Among Medicare Beneficiaries: The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

Background

Better cardiovascular health is associated with lower cardiovascular disease risk.

Methods and Results

We determined the association between cardiovascular health and healthcare utilization and expenditures in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. We included 6262 participants ≥65 years with Medicare fee‐for‐service coverage for the year after their baseline study visit in 2003‐2007. Cardiovascular health at baseline was assessed using the American Heart Association's Life's Simple 7 (LS7) metric, which includes 7 factors: cigarette smoking, physical activity, diet, body mass index, blood pressure, cholesterol, and glucose. Healthcare utilization and expenditures were ascertained using Medicare claims in the year following baseline. Overall, 17.2%, 31.1%, 29.0%, 16.4% and 6.4% of participants had 0 to 1, 2, 3, 4, and 5 to 7 ideal LS7 factors, respectively. The multivariable‐adjusted relative risk (95% confidence interval [CI]) for having any inpatient and outpatient encounters comparing participants with 5 to 7 versus 0 to 1 ideal LS7 factors were 0.55 (0.39, 0.76) and 1.00 (0.98, 1.02), respectively. Among participants with 0 to 1 and 5 to 7 ideal LS7 factors, mean inpatient expenditures were $3995 and $1250, respectively, mean outpatient expenditures were $5166 and $2853, respectively, and mean total expenditures were $9147 and $4111, respectively. After multivariable adjustment, the mean (95% CI) cost difference comparing participants with 5 to 7 versus 0 to 1 ideal LS7 factors was −$2551 (−$3667, −$1435) for inpatient, −$2410 (−$3089, −$1731) for outpatient, and −$5016 (−$6577, −$3454) for total expenditures.

Conclusions

Better cardiovascular health is associated with lower risk for inpatient encounters and lower inpatient and outpatient healthcare expenditures.

Meals Enhancing Nutrition After Discharge: Findings from a Pilot Randomized Controlled Trial

BACKGROUND

After older adults experience episodes of poor health or are hospitalized, they may not return to premorbid or prehospitalization eating behaviors. Furthermore, poor nutrition increases hospital readmission risk, but evidence-based interventions addressing these risks are limited.

OBJECTIVE

This pilot study's objective was to evaluate the feasibility of conducting a randomized controlled trial assessing a post-discharge home-delivered meal program's impact on older adults' nutritional intake and hospital readmissions and to assess patient acceptability and satisfaction with the program. The aims of the study were to evaluate successful recruitment, randomization, and retention of at least 80% of the 24 participants sought; to compare the outcomes of hospital readmission and total daily caloric intake between participants in the intervention and control groups; and to assess patient acceptability and satisfaction with the program.

DESIGN

This study used a two-arm randomized controlled trial design, and baseline data were collected at enrollment; three 24-hour food recalls were collected during the intervention period; and health services utilization and intervention satisfaction was evaluated 45 days post-discharge.

PARTICIPANTS/SETTING

Twenty-four patients from the University of Alabama at Birmingham Hospital's Acute Care for Elders (ACE) Unit were enrolled from May 2014 to June 2015. They were 65 years or older; at risk for malnutrition; cognitively intact; able to communicate; discharged to a place where the patient or family was responsible for preparing meals; and diagnosed with congestive heart failure, chronic obstructive pulmonary disease, acute myocardial infarction, or pneumonia. Final analysis included 21 participants.

INTERVENTION

The intervention group received 10 days of home-delivered meals and nutrition education; the control group received usual care and nutrition education.

MAIN OUTCOME MEASURES

The main outcome was intervention feasibility, measured by recruitment and retention goals. Hospital readmissions, caloric intake, and satisfaction with the intervention were also evaluated.

STATISTICAL ANALYSES PERFORMED

Univariate and bivariate parametric statistics were used to evaluate differences between groups. Goals for success were identified to assess feasibility of conducting a full-scale study and outcomes were measured against the goals.

RESULTS

Of the randomized participants, 87.5% were retained for final data collection, indicating that this intervention study is feasible. There were no significant differences between groups for hospital readmissions; however, caloric intake during the intervention period was greater for intervention vs control participants (1,595 vs 1,235; P=0.03). Participants were overwhelmingly satisfied (82% to 100% satisfied or very satisfied) with staff performance, meal quality, and delivery processes.

CONCLUSIONS

Conducting a randomized controlled trial to assess outcomes of providing home-delivered meals to older adults after hospital discharge in partnership with a small nonprofit organization is feasible and warrants future research.

Detailed methods of two home-based vegetable gardening intervention trials to improve diet, physical activity, and quality of life in two different populations of cancer survivors

BACKGROUND

Cancer survivors suffer from long-term adverse effects that reduce health-related quality of life (QOL) and physical functioning, creating an urgent need to develop effective, durable, and disseminable interventions. Harvest for Health, a home-based vegetable gardening intervention, holds promise for these domains.

METHODS

This report describes the methods and recruitment experiences from two randomized controlled feasibility trials that employ a waitlist-controlled design. Delivered in partnership with Cooperative Extension Master Gardeners, this intervention provides one-on-one mentorship of cancer survivors in planning and maintaining three seasonal vegetable gardens over 12months. The primary aim is to determine intervention feasibility and acceptability; secondary aims are to explore effects on objective and subjective measures of diet, physical activity and function, and QOL and examine participant factors associated with potential effects. One trial is conducted exclusively among 82 female breast cancer survivors residing in the Birmingham, AL metropolitan area (BBCS); another broadly throughout Alabama among 46 older cancer survivors aged >60 (ASCS).

RESULTS

Response rates were 32.6% (BBCS) and 52.3% (ASCS). Both trials exceeded 80% of their accrual target. Leading reasons for ineligibility were removal of >10 lymph nodes (lymphedema risk factor), lack of physician approval, and unwillingness to be randomized to the waitlist.

CONCLUSION

To date, recruitment and implementation of Harvest for Health appears feasible.

DISCUSSION

Although both studies encountered recruitment challenges, lessons learned can inform future larger-scale studies. Vegetable gardening interventions are of interest to cancer survivors and may provide opportunities to gain life skills leading to improvements in overall health and QOL.

Distinct age and self-rated health crossover mortality effects for African Americans: Evidence from a national cohort study

The predictive effects of age and self-rated health (SRH) on all-cause mortality are known to differ across race and ethnic groups. African American adults have higher mortality rates than Whites at younger ages, but this mortality disparity diminishes with advancing age and may "crossover" at about 75-80 years of age, when African Americans may show lower mortality rates. This pattern of findings reflects a lower overall association between age and mortality for African Americans than for Whites, and health-related mechanisms are typically cited as the reason for this age-based crossover mortality effect. However, a lower association between poor SRH and mortality has also been found for African Americans than for Whites, and it is not known if the reduced age and SRH associations with mortality for African Americans reflect independent or overlapping mechanisms. This study examined these two mortality predictors simultaneously in a large epidemiological study of 12,181 African Americans and 17,436 Whites. Participants were 45 or more years of age when they enrolled in the national REasons for Geographic and Racial Differences in Stroke (REGARDS) study between 2003 and 2007. Consistent with previous studies, African Americans had poorer SRH than Whites even after adjusting for demographic and health history covariates. Survival analysis models indicated statistically significant and independent race*age, race*SRH, and age*SRH interaction effects on all-cause mortality over an average 9-year follow-up period. Advanced age and poorer SRH were both weaker mortality risk factors for African Americans than for Whites. These two effects were distinct and presumably tapped different causal mechanisms. This calls into question the health-related explanation for the age-based mortality crossover effect and suggests that other mechanisms, including behavioral, social, and cultural factors, should be considered in efforts to better understand the age-based mortality crossover effect and other longevity disparities.

Challenges to Healthy Eating Practices: A Qualitative Study of Non-Hispanic Black Men Living With Diabetes

PURPOSE

The purpose of this study was to explore current dietary practices and perceived barriers to healthy eating in non-Hispanic black men with type 2 diabetes.

METHODS

Four 90-minute focus groups held in September and October 2011 were led by a trained moderator with a written guide to facilitate discussion on dietary practices and barriers to healthy eating. Participants were recruited from the diabetes database at a public safety-net health system in Jefferson County, Alabama. Two-independent reviewers performed content analysis to identify major themes using a combined deductive and inductive approach.

RESULTS

There were 34 male participants aged 18 years and older. Mean years living with diabetes was 9.6 ± 5.9. Sixty-two percent of participants perceived themselves to be in fair or poor health. Participants' self-reported eating practices did not always relate to hunger. Internal cues to eat included habit and response to emotions, and external cues to eat included media messaging, medication regimens, and work schedules. Men identified multiple barriers to healthy eating including hard-to-break habits, limited resources and availability of food at home and in neighborhood grocery stores, and perceived poor communication with health care professionals.

CONCLUSION

Non-Hispanic black men acknowledged the importance of healthy eating as part of diabetes self-management but reported various internal and external challenges that present barriers to healthy eating. Tailored strategies to overcome barriers to healthy eating among non-Hispanic black men should be developed and tested for their impact on diabetes self-management.

Calorie restriction in overweight older adults: Do benefits exceed potential risks?

The evidence regarding recommendations of calorie restriction as part of a comprehensive lifestyle intervention to promote weight loss in obese older adults has remained equivocal for more than a decade. The older adult population is the fastest growing segment of the US population and a greater proportion of them are entering old age obese. These older adults require treatments based on solid evidence. Therefore the purpose of this review is three-fold: 1) to provide a more current status of the knowledge regarding recommendations of calorie restriction as part of a comprehensive lifestyle intervention to promote weight loss in obese older adults, 2) to determine what benefits and/or risks calorie restriction adds to exercise interventions in obese older adults, and 3) to consider not only outcomes related to changes in body composition, bone health, cardiometabolic disease risk, markers of inflammation, and physical function, but, also patient-centered outcomes that evaluate changes in cognitive status, quality of life, out-of-pocket costs, and mortality. Seven randomized controlled trials were identified that examined calorie restriction while controlling for exercise intervention effects. Overall, the studies found that calorie restriction combined with exercise is effective for weight loss. Evidence was mixed regarding other outcomes. The risk-benefit ratio regarding calorie restriction in older adults remains uncertain. Greater long-term follow-up is necessary, and complementary effectiveness studies are needed to identify strategies currently used by obese older adults in community settings.

The effects of state-level expenditures for home- and community-based services on the risk of becoming a long-stay nursing home resident after hip fracture

SUMMARY

This study measures the effect of spending policies for long-term care services on the risk of becoming a long-stay nursing home resident after a hip fracture. Relative spending on community-based services may reduce the risk of long-term nursing home residence. Policies favoring alternative sources of care may provide opportunities for older adults to remain community-bound.

INTRODUCTION

This study aims to understand how long-term care policies affect outcomes by investigating the effect of state-level spending for home- and community-based services (HCBSs) on the likelihood of an individual's nursing home placement following hip fracture.

METHODS

This study uses data from the 5% sample of Medicare beneficiaries from 2005 to 2010 to identify incident hip fractures among dual-eligibility, community-dwelling adults aged at least 65 years. A multilevel generalized estimating equation (GEE) model estimated the association between an individual's risk of nursing home residence within 1 year and the percent of states' Medicaid long-term support service (LTSS) budget allocated to HCBS. Other covariates included expenditures for Title III services and individual demographic and health status characteristics.

RESULTS

States vary considerably in HCBS spending, ranging from 17.7 to 83.8% of the Medicaid LTSS budget in 2009. Hip fractures were observed from claims among 7778 beneficiaries; 34% were admitted to a nursing home and 25% died within 1 year. HCBS spending was associated with a decreased risk of nursing home residence by 0.17 percentage points (p 0.056).

CONCLUSIONS

Consistent with other studies, our findings suggest that state policies favoring an emphasis on HCBS may reduce nursing home residence among low-income older adults with hip fracture who are at high risk for institutionalization.

Alone at the Table: Food Behavior and the Loss of Commensality in Widowhood

OBJECTIVES

Eating alone is a known risk factor for nutritional vulnerability in later life. Widowhood often entails loss of commensality (shared meals). This article explores this experience among older widowed women in relation to food behavior.

METHOD

Qualitative methods based on constructivist grounded theory were used. Interviews were conducted with 15 women living alone in the community, aged 71 to 86 years, and widowed 6 months to 15 years.

RESULTS

Widowhood meant having significantly fewer opportunities for commensality. Participants attributed changes to their food behaviors to the loss of commensality, including food choice, fewer regular meals, and reduced work of meal preparation. These changes were attributed to the experienced difference between shared meals and meals eaten alone, no longer having the commitment of commensality, and having less interest in meal preparation in the absence of obligation or reward of commensality.

DISCUSSION

Eating alone symbolized loss and was less enjoyable, yet the pleasure experienced with food was intact. Focusing on the pleasure of eating may help support women when they lose regular commensality late in life. Free from the commitment of commensality, some shifted away from regular meals and simplified their meal preparation strategies. This has implications for clinical and research endeavors.

Does Participation in Home-Delivered Meals Programs Improve Outcomes for Older Adults? Results of a Systematic Review

Participation in home-delivered meals programs may contribute to the health and independence of older adults living in the community, especially those who are food insecure or those who are making transitions from acute, subacute, and chronic care settings to the home. The purpose of this study was to conduct a comprehensive and systematic review of all studies related to home-delivered meals in order to shed light on the state of the science. A complete review of articles appearing in PubMed using the keyword "Meal" was conducted; and titles, abstracts, and full-texts were screened for relevance. Included in this review are 80 articles. Most studies are descriptive and do not report on outcomes. Frequently reported outcomes included nutritional status based on self-reported dietary intake. Additionally, most studies included in this review are cross-sectional, have a small sample size, and/or are limited to a particular setting or participant population. More rigorous research is needed to (1) gain insight into why so few eligible older adults access home-delivered meals programs, (2) support expansion of home-delivered meals to all eligible older adults, (3) better identify what home-delivered meals models alone and in combination with other services works best and for whom, and (4) better target home-delivered meals programs where and when resources are scarce.

The influence of gender, age, education and household size on meal preparation and food shopping responsibilities

OBJECTIVE

To examine the extent to which the gendered division of labour persists within households in the USA in regard to meal planning/preparation and food shopping activities.

DESIGN

Secondary analysis of cross-sectional data.

SETTING

2007-2008 US National Health and Nutrition Examination Survey.

SUBJECTS

Sub-sample of 3195 adults at least 20 years old who had a spouse or partner.

RESULTS

Analyses revealed that the majority of women and men reported they shared in both meal planning/preparing and food shopping activities (meal planning/preparation: women 54 % and men 56 %; food shopping: women 60 % and men 57 %). Results from multinomial logistic regression analyses indicated that, compared with men, women were more likely to take primary responsibility than to share this responsibility and less likely to report having no responsibility for these tasks. Gender differences were observed for age/cohort, education and household size.

CONCLUSIONS

This study may have implications for public health nutritional initiatives and the well-being of families in the USA.

Neighborhood Disadvantage, Preconception Health Behaviors and Infant Birthweight: A Preliminary Study

Prior studies have shown that neighborhood disadvantage and disorder are associated with birth outcomes. This study examined preconception diet and physical activity level, as well as body mass index, as mediators of the association between neighborhood conditions and birthweight. Secondary data analyses were conducted using data from the National Longitudinal Study of Adolescent Health (Add Health). The final analytic sample consisted of 523 adolescent and young adult mothers giving singleton live births between 1997 and 1998. In contrast to previous research, we found that neighborhood characteristics were unrelated to birthweight. Consistent with prior studies, compared to those who were White, on average, Blacks had birthweights that were 163.25 grams lighter. In addition, compared to mothers who were married or living with a partner, mothers who did not have a partner at the time of birth, on average, had offspring that were 127.20 grams lighter. No evidence was found for the mediation hypotheses as there were no associations between neighborhood characteristics and preconception diet or physical activity or between these behavioral variables and birthweight. To the authors' knowledge, this is the first study examining diet and physical activity as possible behavioral pathways between the neighborhood context and birthweight.

Nutritional risk and body mass index predict hospitalization, nursing home admissions, and mortality in community-dwelling older adults: results from the UAB Study of Aging with 8.5 years of follow-up

BACKGROUND

Nutritional risk and low BMI are common among community-dwelling older adults, but it is unclear what associations these factors have with health services utilization and mortality over long-term follow-up. The aim of this study was to assess prospective associations of nutritional risk and BMI with all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality over 8.5 years.

METHODS

Data are from 1,000 participants in the University of Alabama at Birmingham Study of Aging, a longitudinal, observational study of older black and white residents of Alabama aged 65 and older. Nutritional risk was assessed using questions associated with the DETERMINE checklist. BMI was categorized as underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9), class I obese (30.0-34.9), and classes II and III obese (≥35.0). Cox proportional hazards models were fit to assess risk of all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality. Covariates included social support, social isolation, comorbidities, and demographic measures.

RESULTS

In adjusted models, persons with high nutritional risk had 51% greater risk of all-cause hospitalization (95% confidence interval: 1.14-2.00) and 50% greater risk of nonsurgical hospitalizations (95% confidence interval: 1.11-2.01; referent: low nutritional risk). Persons with moderate nutritional risk had 54% greater risk of death (95% confidence interval: 1.19-1.99). BMI was not associated with any outcomes in adjusted models.

CONCLUSIONS

Nutritional risk was associated with all-cause hospitalizations, nonsurgical hospitalizations, and mortality. Nutritional risk may affect the disablement process that leads to health services utilization and death. These findings point to the need for more attention on nutritional assessment, interventions, and services for community-dwelling older adults.

Calorie restriction in overweight seniors: response of older adults to a dieting study: the CROSSROADS randomized controlled clinical trial

We conducted a study designed to evaluate whether the benefits of intentional weight loss exceed the potential risks in a group of community-dwelling obese older adults who were at increased risk for cardiometabolic disease. The CROSSROADS trial used a prospective randomized controlled design to compare the effects of changes in diet composition alone or combined with weight loss with an exercise only control intervention on body composition and adipose tissue deposition (Specific Aim #1: To compare the effects of changes in diet composition alone or combined with weight loss with an exercise only control intervention on body composition, namely visceral adipose tissue), cardiometabolic disease risk (Specific Aim #2: To compare the effects of a change in diet composition alone or combined with weight loss with an exercise only control intervention on cardiometabolic disease risk), and functional status and quality of life (Specific Aim #3: To compare the effects of a change in diet composition alone or combined with weight loss with an exercise only control intervention on functional status and quality of life). Participants were randomly assigned to one of three groups: Exercise Only (Control) Intervention, Exercise + Diet Quality + Weight Maintenance Intervention, or Exercise + Diet Quality + Weight Loss Intervention. CROSSROADS utilized a lifestyle intervention approach consisting of exercise, dietary, and behavioral components. The development and implementation of the CROSSROADS protocol, including a description of the methodology, detailing specific elements of the lifestyle intervention, assurances of treatment fidelity, and participant retention; outcome measures and adverse event monitoring; as well as unique data management features of the trial results, are presented in this article.

A state-level examination of the association between home and community-based services and rates of nursing home residency with special attention to nutrition programs

Federal food and nutrition programs implemented by the Administration on Aging and funded by the Older Americans Act (OAA) seek to enable older adults to remain in their homes and communities through a comprehensive, coordinated, and cost-effective array of services. We hypothesized that expenditures devoted to nutrition programs for home and community-based nutrition services were inversely related to changes in state-level rates of institutionalization for older adults from one year to the next, such that states that spend more money per capita on community-based nutrition programs would have smaller increases or greater decreases in rates of institutionalization, controlling for expenditures on other home and community-based services. We found, however, that there was not an effect of OAA Nutrition Services on the change in rates of nursing home residency. We noted, though, that states that direct a greater proportion of their long-term care expenditures to home and community-based services appear to have more reduction in their rates of nursing home residency. Further longitudinal work at the state and individual levels is warranted.

Dietary patterns are associated with incident stroke and contribute to excess risk of stroke in black Americans

BACKGROUND AND PURPOSE

Black Americans and residents of the Southeastern United States are at increased risk of stroke. Diet is one of many potential factors proposed that might explain these racial and regional disparities.

METHODS

Between 2003 and 2007, the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study enrolled 30 239 black and white Americans aged≥45 years. Dietary patterns were derived using factor analysis and foods from food frequency data. Incident strokes were adjudicated using medical records by a team of physicians. Cox-proportional hazards models were used to examine risk of stroke.

RESULTS

During 5.7 years, 490 incident strokes were observed. In a multivariable-adjusted analysis, greater adherence to the plant-based pattern was associated with lower stroke risk (hazard ratio, 0.71; 95% confidence interval, 0.56-0.91; Ptrend=0.005). This association was attenuated after addition of income, education, total energy intake, smoking, and sedentary behavior. Participants with a higher adherence to the Southern pattern experienced a 39% increased risk of stroke (hazard ratio, 1.39; 95% confidence interval, 1.05, 1.84), with a significant (P=0.009) trend across quartiles. Including Southern pattern in the model mediated the black-white risk of stroke by 63%.

CONCLUSIONS

These data suggest that adherence to a Southern style diet may increase the risk of stroke, whereas adherence to a more plant-based diet may reduce stroke risk. Given the consistency of finding a dietary effect on stroke risk across studies, discussing nutrition patterns during risk screening may be an important step in reducing stroke.

Symptom burden predicts nursing home admissions among older adults

CONTEXT

Symptom burden has been associated with functional decline in community-dwelling older adults and may be responsive to interventions. Known predictors of nursing home (NH) admission are often nonmodifiable.

OBJECTIVES

To determine if symptom burden independently predicted NH admission among community-dwelling older adults over an eight and a half-year follow-up period.

METHODS

A random sample of community-dwelling Medicare beneficiaries in Alabama, stratified by race, gender, and rural/urban residence had baseline in-home assessments of sociodemographic measurements, Charlson comorbidity count, and symptoms. Symptom burden was derived from a count of 10 patient-reported symptoms. Nursing home admissions were determined from telephone interviews conducted every six months over the eight and a half years of study. Cox proportional hazard modeling was used to examine the significance of symptom burden as a predictor for NH admission after adjusting for other variables.

RESULTS

The mean ± SD age of the sample (N = 999) was 75.3 ± 6.7 years, and the sample was 51% rural, 50% African American, and 50% male. Thirty-eight percent (n = 380) had symptom burden scores ≥2. Seventy-five participants (7.5%) had confirmed dates for NH admission during the eight and a half years of follow-up. Using Cox proportional hazard modeling, symptom burden remained an independent predictor of time to NH placement (hazard ratio = 1.11; P = 0.02), even after adjustment for comorbidity count, race, sex, and age.

CONCLUSION

Symptom burden is an independent risk factor for NH admission. Aggressive management of symptoms in older adults may reduce or delay NH admission.

Multimodal intervention to improve osteoporosis care in home health settings: results from a cluster randomized trial

SUMMARY

We conducted a cluster randomized trial testing the effectiveness of an intervention to increase the use of osteoporosis medications in high-risk patients receiving home health care. The trial did not find a significant difference in medication use in the intervention arm.

INTRODUCTION

This study aims to test an evidence implementation intervention to improve the quality of care in the home health care setting for patients at high risk for fractures.

METHODS

We conducted a cluster randomized trial of a multimodal intervention targeted at home care for high-risk patients (prior fracture or physician-diagnosed osteoporosis) receiving care in a statewide home health agency in Alabama. Offices throughout the state were randomized to receive the intervention or to usual care. The primary outcome was the proportion of high-risk home health patients treated with osteoporosis medications. A t test of difference in proportions was conducted between intervention and control arms and constituted the primary analysis. Secondary analyses included logistic regression estimating the effect of individual patients being treated in an intervention arm office on the likelihood of a patient receiving osteoporosis medications. A follow-on analysis examined the effect of an automated alert built into the electronic medical record that prompted the home health care nurses to deploy the intervention for high-risk patients using a pre-post design.

RESULTS

There were 11 offices randomized to each of the treatment and control arms; these offices treated 337 and 330 eligible patients, respectively. Among the offices in the intervention arm, the average proportion of eligible patients receiving osteoporosis medications post-intervention was 19.1 %, compared with 15.7 % in the usual care arm (difference in proportions 3.4 %, 95 % CI, -2.6 to 9.5 %). The overall rates of osteoporosis medication use increased from 14.8 % prior to activation of the automated alert to 17.6 % afterward, a nonsignificant difference.

CONCLUSIONS

The home health intervention did not result in a significant improvement in use of osteoporosis medications in high-risk patients.

A randomized controlled trial of a theoretically-based behavioral nutrition intervention for community elders: lessons learned from the Behavioral Nutrition Intervention for Community Elders Study

Older adults with multiple comorbidities are often undernourished or at high risk for becoming so, especially after a recent hospitalization. Randomized controlled trials of effective, innovative interventions are needed to support evidence-based approaches for solving nutritional problems in this population. Self-management approaches where participants select their own behavioral goals can enhance success of interventions. The purpose of this study was to evaluate the feasibility and efficacy of a multilevel self-management intervention to improve nutritional status in a group of high-risk older adults. The Behavioral Nutrition Intervention for Community Elders (B-NICE) trial used a prospective randomized controlled design to determine whether the intervention, compared to standard care, maintained or increased caloric intake (depending on baseline body mass index) and, consequently, stabilized or increased body weight. Participants were 34 Medicare-eligible, age 65 years old or older, homebound adults who were consuming insufficient calories and/or had a history of weight loss ≥2.5% over 6 months. The intervention took place within participants' homes. Outcome measures, including energy intake (based on collection of three 24-hour dietary recalls) and body weights were assessed at baseline and at 60 days post randomization. The primary analyses included analyses of covariance and Pearson's χ(2). We hypothesized that the intervention would result in increased caloric intake and weight gain in underweight older adults and increased or stabilized caloric intake and weight for everyone else. The intervention was feasible; however, it did not result in differences between groups for desired outcomes of either caloric intake or body weight. Future interventions might either deliberately involve caregivers or reduce burden for both patients and caregivers.

Harvest for health gardening intervention feasibility study in cancer survivors

BACKGROUND

Cancer survivors are at increased risk for second malignancies, cardiovascular disease, diabetes, and functional decline. Evidence suggests that a healthful diet and physical activity may reduce the risk of chronic disease and improve health in this population.

METHODS

We conducted a feasibility study to evaluate a vegetable gardening intervention that paired 12 adult and child cancer survivors with Master Gardeners to explore effects on fruit and vegetable intake, physical activity, quality-of-life, and physical function. Throughout the year-long study period, the survivor-Master Gardener dyads worked together to plan/plant three gardens, harvest/rotate plantings, and troubleshoot/correct problems. Data on diet, physical activity, and quality-of-life were collected via surveys; anthropometrics and physical function were objectively measured. Acceptability of the intervention was assessed with a structured debriefing survey.

RESULTS

The gardening intervention was feasible (robust enrollment; minimal attrition) and well-received by cancer survivors and Master Gardeners. Improvement in three of four objective measures of strength, agility, and endurance was observed in 90% of survivors, with the following change scores [median (interquartile range)] noted between baseline and one-year follow-up: hand grip test [+ 4.8 (3.0, 6.7) kg], 2.44 meter Get-Up-and-Go [+ 1.0 (+ 1.8, + 0.2) seconds], 30-second chair stand [+ 3.0 (+ 1.0, 5.0) stands], and six-minute walk [+ 11.6 (6.1, 48.8) meters]. Increases of ≥ 1 fruit and vegetable serving/day and ≥ 30 minutes/week of physical activity were observed in 40% and 60%, respectively.

CONCLUSION

These preliminary results support the feasibility and acceptability of a mentored gardening intervention and suggest that it may offer a novel and promising strategy to improve fruit and vegetable consumption, physical activity, and physical function in cancer survivors. A larger randomized controlled trial is needed to confirm our results.

Patterns of prophylactic gastrostomy tube placement in head and neck cancer patients: a consideration of the significance of social support and practice variation

OBJECTIVES/HYPOTHESIS

The purpose of this study was to examine factors associated with prophylactic placement of feeding tubes in head and neck cancer patients receiving radiation therapy as a part of treatment using multilevel models that account for patient-, physician-, and institution-level sources of variation.

STUDY DESIGN

A retrospective analysis using binary logistic regression and hierarchical linear models was run to evaluate independent predictors of prophylactic feeding tube placement.

METHODS

Surveillance, Epidemiology, and End Results-Medicare data were used. Head and neck cancer patients diagnosed with locoregionally advanced stage disease from 2000 to 2005 were included in this study (N = 8,306).

RESULTS

Across all models, prophylactic gastrostomy tube placement was found to be more likely in patients who had cancer of the larynx or oropharynx compared with those with cancer of the nasopharynx or oral cavity; who had regional instead of local cancer; who did not receive surgery as a part of treatment, but did receive chemotherapy; and who were divorced, separated, or widowed. Additionally, although practice variation was observed to occur, its overall contribution in predicting prophylactic gastrostomy tube placement was minimal.

CONCLUSIONS

As health care enters an era of patient-centered care, further investigation of the potential role of social support (or lack of social support) in influencing treatment decisions of head and neck cancer patients and providers is warranted.